Medical review

Under Beneficiary and Family Centered Care (BFCC), MPRO also relies on an extensive network of physicians to conduct Medical Reviews. During this process, MPRO physicians:

• Determine if a quality of care problem exists and if professionally-recognized standards of care were met;
• In the event of a concern, MPRO sends a letter to the provider or physician; and;
• Physicians/providers have the opportunity to respond first in writing and then speak with a physician reviewer to discuss the case;
• Determine if the beneficiary is ready for the next level of care or if the beneficiary continues to need Medicare acute or skilled services;
• Review if the appropriate codes were used for submitted claims; and
• Determine if the healthcare setting was the most appropriate for the beneficiary,

Individual patient complaints and provider medical reviews are important steps for analyzing and discovering quality improvement needs among providers. Ultimately, this is a positive scenario which can create opportunities for providers to implement proven quality improvement efforts.

Related Links:

• Become a Physician Reviewer
• Beneficiary and Family Centered Care Overview
• Medicare QIO Requests for Review (Formerly Known as Beneficiary Appeals)
• Inpatient/Outpatient Quality Reporting & Improvement
• Access to Community Zero/Beneficiary Protection
• Beneficiary Notices Initiative